A patient from Wisconsin with health insurance coverage through Blue Cross and Blue Shield of Tennessee (BCBST) was receiving treatment for neurofibromatosis type two (NF2) at the Mayo Clinic in Rochester, Minnesota. The patient’s treatment team recommended that a cochlear implant be implanted to provide adequate hearing in her left ear that would otherwise be completely deaf.
The Mayo Clinic requested prior authorization from BCBST for this service on December 3, 2021. The Mayo Clinic then submitted an appeal on December 15, 2021, but their request was denied by BCBST on January 11, 2022. When the Mayo Clinic submitted a second appeal to BCBST on February 9, 2022, their request was (wrongfully) denied on the basis that all provider appeals had been exhausted. Later, the Mayo Clinic initiated a second prior authorization request, which was denied on May 19, 2022.
This family reached out to the team at FixMyClaim in May 2022 for assistance submitting an appeal for this cochlear device implant procedure. In analyzing the denial letter, our experts noted that BCBST denied coverage based on clinical criteria developed by MCG Health (formerly Milliman Care Guidelines). In order to effectively appeal this denial, it was necessary to request a copy of the exact criteria used from BCBST. The team at FixMyClaim requested the relevant criteria on June 17, 2022, and received a response from BCBST on July 14, 2022.
Using all of the available information and documentation, the appeals team at FixMyClaim prepared an extensive level one member appeal package totaling 108 pages, which was submitted to BCBST on September 2, 2022. BCBST sent a letter dated September 8, 2022, acknowledging their receipt of the appeal on September 6, 2022. On September 26, 2022, BCBST concluded that the denial should be overturned. This patient was able then to undergo the cochlear implant procedure on October 28, 2022, and BCBST paid over $67,000.00 to the Mayo Clinic for the corresponding claim on November 20, 2022.
FMC5_3427